Neonatology

Question 1

What is a cephalhaematoma?

Answer 1

Subperioesteal accumulation of blood, confined within the margins of the skull sutures and usually involves the parietal bone.

Question 2

How to manage a cephalhaematoma?

Answer 2

Observation. It takes a few weeks to resolve. Do not aspirate/drain. There is an imcreased risk of neonatal jaundice, so keep an eye out for that.

Question 3

Infant of diabetic mother complications?

Answer 3

LGA, hypoglycemia, hypocalcemia, polycythemia, jaundice, RDS

Question 4

Macrosomia complications?

Answer 4

Hypoxia, cephalhaematoma, facial nerve injury, clavicular fracture, shoulder dystochia, brachial plexus injury

Question 5

How to treat hypoglycaemia?

Answer 5

Frequent feeding, if Severe give IV bolus dextrose 10% 2ml/kg
Also give IV fluids: dextrose 10% at 60ml/kg/day

Question 6

What do you see on CXR of RDS

Answer 6

hypoaeration, diffuse granular reticular pattern (ground glass), air bronchograms, low lung volume, diffuse white out of severe

Question 7

Investigations for pathological/prolonged jaundice

Answer 7

Bedside: transcutaneous bilirubin, Guthrie heel prick test, urine MC&S
Serum: G6PD, TSH
Blood: serum bilirubin, FBC, PBF, reticulocyte, blood group, direct antibody test, Coombs test, UEC, LFT, TFT, septic workup if infection suspected

Question 8

When does a baby with jaundice need exchange transfusion

Answer 8

Severely elevated serum bilirubin > 20mg/dl or 349 micromol/l

Question 9

Ddx for RDS

Answer 9

GBS pneumonia, TTN, MAS, congenital lobar emphysema

Question 10

How to manage RDS

Answer 10

Admit to NICU
Maintain airway and monitor O2
Administer surfactant via ETT
Ventilation:
- O2 therapy
- intubation and intermittent PPV if bradycardic, FiO2 > 40%, severe recurrent apnea, resp failure)
- oral feeding if tolerated otherwise IV fluids and TPN If not feeding after 72 hrs
- IV bicarbonate if metabolic acidosis
- empirical antibiotics till blood cultures negative, gentamicin + penicilllin

Question 11

Features of ABO incompatibility

Answer 11

• infants Hb normal or slightly decreased
• no hepatosplenomegaly
• Coombs test positive
• jaundice peaks in first 12-72 hours, severe

Question 12

Managing Rh incompatibility

Answer 12

Regular ultrasound to detect anemia via Doppler of MCA

Might need regular blood transfusions via umbilical vein from 20 weeks

Question 13

How to manage humerus/femur fracture at birth

Answer 13

Immobilize, will heal fast

Question 14

How to manage nerve palsies like brachial and erb’s

Answer 14

Most resolve on their own, but if still present at 2-3 months refer to Ortho/plastic surgeon. Most Will resolve at 2 years

Question 15

Managing facial nerve palsy

Answer 15

Methylcellulose might be needed for the eye, but otherwise transient

Unilateral facial weakness on crying but eye remains open

Question 16

Tests for neonatal sepsis

Answer 16

Urinalysis + MC&S
FBC, ESR, CRP 
3xBlood cultures 
CXR 
LP

Question 17

Management for neonatal sepsis

Answer 17

Admit 
Do septic workup if indicated 
Monitor FBG and VBG
Empiric antibiotics 
- early onset: benpen + gentamicin 
- late onset: flucloxacillin + gentamicin unless CNS infection, then cefotaxime 
Duration of antibiotics 
- 7-10 days for pneumonia or proven sepsis 
- 14 days for GBS meningitis 
- 21 days for Gram-ve meningitis

Question 18

when does early onset sepsis present

Answer 18

Within 72 hours

Question 19

Early Complications of very preterm babies or LBW babies

Answer 19

Respiratory: RDS, apnoea and bradycardia (managed by respiratory stimulants, CPAP)
Hepatic: hypoglycemia, hyperbilirubinemia, hyperglycemia
Renal: Hyponatremia, hyperkalemia, metabolic acidosis
Cardiac: PDA
GIT: Feeding problems (manage via IV nutrition, then slowly intro BF), NEC
Neuro: intraventricular hemorrhage (within 72 hours, so must do ultrasound and measure head circ), periventricular leukomalacia (risk of spastic Diplegia, cog impairment)
MSK: rickets
Other: IDA, infection, hypothermia (large surface area, thin skin, less subcut fat)

Question 20

Late complications of very preterm or LBW infants

Answer 20

Delayed growth - don’t grow for 2-3 weeks post birth, catch up in first 2 years
BPD - chronic lung dx, need supplemental o2 at 37 weeks PGA
Retinopathy of prematurity - disruption of vascularisation of retina causes fibrous scarring and detachment if severely, need laser therapy)
Neurodevelopmental delay - CP, mental retardation, blindness or deafness
Hearing impairment, inguinal hernia

Question 21

How to manage preterm infants (in NICU)

Answer 21

Admit to NICU
Monitor vitals, cardioresp and SaO2
Monitor with EEG
Monitor for hypoglycemia and electrolyte imbalance
Monitor in incubator and thermoreg functions 4 hrly
Put baby on resp support and maintain SpO2 between 89% to 95%
- CPAP if baby have apnoea
Intermittent skin to skin care
Establish feeding of baby within 90 mins of birth, offer feeding every 3 hours (if not possible, IV nutrition)
Document baby’s urine and stool output, colour, frequency
Discharge when:
- baby maintains temperature
- feeding well, weight gain of 3g or more a day
- appropriate ikmmunization and metabolic screen done
- fundoscopy and hearing evaluation done
Arrange for home-nursing visits

Question 22

Stabilizing preterm/sick infants

Answer 22

Airway, breathing: clear airway, oxygen/high-flow humidified oxygen/CPAP, mechanical ventilation
Monitoring: Sa02, vitals, blood glucose, blood gases, weight
Temp control: place in plastic bag if extremely preterm otherwise in incubator
Peripheral IV line: for IV fluids, antibiotics etc
Umbilical venous catheter: if extremely preterm/for high-conc dextrose/inotropes
Arterial line: if frequent blood gas analysis, blood test, continuous Bp monitoring
Central venous line if indicated
CXR
IX: FBC, BUSE, creat, lactate, blood culture + csf + urine, blood glucose, CRP, coag if indicated
Broad-spectrum antibiotics
Minimal handling and analgesia
Parents

Question 23

Clinical diagnosis of hypoxic-ischemic encephalopathy

Answer 23

• cardiorespiratory and neurological depression

- evidence of acute hypoxic compromise with acidemia, arterial cord blood ph < 7 and base excess > - 12mmol/L

Question 24

HIE multi-organ dysfunction

Answer 24

Encephalopathy: abnormal neuro signs, seizures
Respiratory: persistent pulmonary hypertension of the newborn
Cardio: hypotension
Metabolic: hypoglycemia, hypocalcemia, hyponatremia
Others: DIVC, renal failure

Question 25

Birth asphyxia If

Answer 25

• evidence of severe hypoxia antenatally, during labour or at delivery
• neonatal resus needed
• encephalopathy features
• characteristic neuroimaging findings
• evidence of hypoxia damage to other organs like liver, kidney, heart
• no other prenatal/postnatal cause identified

Question 26

Monitoring for prolonged jaundice

Answer 26

Must screen all babies at day 14 if term, day 21 if preterm and tests as before

Question 27

Jaundice level in infants

Answer 27

> 85 micromol/l (5mg/dl)